Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: A pilot study

Association between pre-procedural anxiety and vomiting in children who undergo procedural sedation and analgesia in the emergency department

INTRODUCTION

Children presenting to the emergency department (ED) often require procedural sedation and analgesia (PSA) prior to procedures. Although ketamine is used widely for PSA safely, there is a risk of adverse effects. Among them, vomiting is significant as it occurs in about 10% of patients and can potentially endanger the airway. Because there is evidence that post-operative complications might be due to anxiety prior to the operation, this study aims to investigate the association between pre-procedural anxiety and vomiting in the ED.

METHODS

In this cohort study, a convenient sample of children aged 2 to 14 years who were a candidate for PSA with ketamine in the ED were enrolled. Anxiety was evaluated using the short version of the modified Yale preoperative anxiety scale (mYAS). Vomiting was recorded during the period of hospitalization in the ED and 24 h after discharge by a phone call. Association between anxiety level and vomiting was analyzed using the independent samples t-test and multivariable logistic regression was used to control for covariates.

RESULTS

102 children were enrolled and 93 were included in final analysis. The mean age of participants was 3.95 ± 1.79 years and 55.9% were male. According to the mYAS, the mean score of anxiety was 48.67 ± 21.78 in the waiting room and 59.10 ± 23.86 in the operating room. The mean score of anxiety was 58.3±25.3 and 51.0±20.7 in the vomiting and non-vomiting groups, respectively. At least one episode of vomiting was reported in 23 children of which, 19 took place in the hospital and 4 after discharge. No significant association was observed between pre-procedural anxiety and the occurrence of vomiting. On univariate regression model, the odds ratio of the association between mean anxiety and vomiting was 1.02 (CI 95%: 0.99-1.04) (P-value: 0.16). On the multivariable logistic regression model, after adjusting for all the covariates, the odds ratio was 1.03 (CI 95%: 1.0-1.05) (P-value: 0.05).

CONCLUSION

The present study showed that anxiety before procedural sedation and analgesia with ketamine in children was not associated with the incidence of vomiting.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Virtual Reality Distraction for Needle-Related Pain and Distress in Children: A Multicenter Randomized Controlled Trial

This international multicenter randomized controlled trial aimed to compare the effectiveness of virtual reality (VR) distraction with an identical non-VR game in reducing needle-related pain and anxiety in children undergoing venous blood draw. The study involved 304 children aged 5-9 years undergoing a blood draw procedure, randomly allocated to one of three groups: VR distraction, non-VR distraction, and control group (usual care). The distraction task was based on the Multiple Object Tracking (MOT) paradigm, and the game was identical in design and gameplay for both VR and non-VR distraction groups. The primary outcome was self-reported pain intensity using the Faces Pain Scale-Revised (FPS-R). Secondary outcomes included child distress, attention/distraction to the blood draw, and parent and medical staff satisfaction with procedure. Analyses were conducted using analysis of variance and multivariable linear regression models. The results showed that VR distraction and non-VR distraction performed similarly, showing large effect sizes compared with standard care. There was no significant difference between the two types of distraction. The study's findings suggest that VR and non-VR distraction are similarly effective in reducing needle-related pain and anxiety in children undergoing venous blood draw. This is the first well-powered study comparing modern VR distraction with an identical task displayed on a smartphone or monitor screen. The study's results have important implications for using VR in clinical settings and suggest that investing in expensive VR equipment for acute pain management may not be necessary. The study protocol was pre-registered on Open Science Framework at https://osf.io/frsyc.

Enhancing pain care with the American Pain Society Patient Outcome Questionnaire for use in the emergency department (APS-POQ-RED): validating a patient-reported outcome measure

BACKGROUND

In general, the quality of pain care in emergency departments (ED) is poor, despite up to 80% of all ED patients presenting with pain. This may be due to the lack of well-validated patient-reported outcome measures (PROMs) of pain care in the ED setting. The American Pain Society-Patient Outcome Questionnaire-Revised Edition (APS-POQ-R), with slight modification for ED patients, is a potentially useful PROM for the adult ED, however it is yet to be completely validated.

METHODS

Adult patients, who had presented with moderate to severe acute pain, were recruited at two large inner-city EDs in Australia. A modified version of the APS-POQ-R was administered at the completion of their ED care. Responses were randomly split into three groups and underwent multiple rounds of exploratory and confirmatory factor analysis with testing for construct, convergent, divergent validity and internal consistency.

RESULTS

A total of 646 ED patients (55.6% female), with a median age of 48.3 years, and moderate to severe pain on arrival, completed the ED-modified APS-POQ-R. Psychometric evaluation resulted in a reduced nine-question tool, which measures three constructs (pain relief and satisfaction (α=0.891), affective distress (α=0.823) and pain interference (α=0.908)) and demonstrated construct, convergent, divergent validity, and internal consistency.

CONCLUSIONS

This new tool, which we refer to as the American Pain Society-Patient Outcome Questionnaire-Revised for the ED (APS-POQ-RED), should form the basis for reporting patient-reported outcomes of ED pain care in future quality improvement and research.

The effects of vibration and pressure interventions on children's pain, fear and anxiety: A randomized controlled trial

AIM

The effects of vibration and pressure methods on the level of fear, anxiety, and pain of pediatric patients who were admitted to the emergency department for intramuscular injection were evaluated.

METHODS

This was a parallel group and a randomized controlled study conducted in Turkey. The study sample consisted of 114 children aged between 5 and 10 years who presented to the emergency department to receive intramuscular ceftriaxone injection as part of their treatment. The children were randomized into three groups: Vibration Intervention Group (n = 38), Pressure Intervention Group (n = 38) and Control Group (n = 38). Before the procedure, the level of anxiety and fear of the children were evaluated, and the level of perceived pain during the procedure was immediately evaluated after the intervention. Parents and nurses also rated the level of pain. Data were analyzed with non-parametric tests using SPSS version 26.0.

RESULTS

According to the evaluations made by children, mothers, and nurses, there was a significant difference between pain scores of children in the vibration and pressure intervention groups during the procedure and children in the control group (p < 0.000). There was a significant difference between anxiety and fear scores of children in the vibration and pressure groups and children in the control group before and after the intervention according to the evaluations of the children, mothers, and nurses (p < 0.000).

CONCLUSION

Vibration and pressure interventions used during intramuscular injections administered to children in the emergency department were found to reduce pain, anxiety, and fear based on the evaluations of children, mothers, and nurses.

PRACTICE IMPLICATIONS

Vibration and pressure are effective and useful in relieving pain associated with intramuscular injections in children aged between 5 and 10 years.

The effect of two different methods on reducing the pain and fear during phlebotomy to children: A randomized controlled trial

INTRODUCTION

Reducing pain and fear during painful medical procedures in children is important since mismanagement of pain causes the child and parent to feel anxious, which can have negative long-term consequences. This study aimed to evaluate the effects of two different distraction methods in reducing pain and fear during the phlebotomy procedure in children.

METHOD

The study, which has a randomized controlled experimental design was conducted between July and October 2020 with 111 children aged 6-12 years who underwent phlebotomy in the emergency department of a public hospital and their parents. The children were randomly assigned to soap bubble blowing (n:37), ball squeezing (n:37) and control (n:37) groups. During the phlebotomy, soap bubble blowing, and ball squeezing methods were used as active distraction methods. Data were collected using the Wong Baker Faces Pain Rating Scale, and the Children's Fear Scale.

RESULTS

The pain scores of the soap bubble blowing group and the ball squeezing group during the phlebotomy procedure were found to be lower than the control group (p < 0.001). In addition, the soap bubble blowing group had lower fear scores than the ball squeezing and control groups (p < 0.001).

CONCLUSION

The active distraction methods used in the study reduced pain and fear during the phlebotomy procedure. In addition, the method of soap bubble blowing was found to be a more effective method in reducing fear. Distraction methods should be used as a nursing intervention to reduce pain and fear during the phlebotomy procedure in children.

Effect of soap bubbles technique, coughing and distraction cards on reducing pain and anxiety during phlebotomy in children

This study aims to compare three techniques (soap bubbles, distraction cards, coughing) to reduce pain and anxiety in children during phlebotomy and collection with the use of a control group. Pain levels of children were assessed with the Wong-Baker FACES Pain Rating Scale and anxiety levels of children were assessed with the Children's Fear Scale. This randomized controlled study involved intervention groups and a control group. The population of this study consisted of 120 Turkish children (30 subjects in each of the four groups soap bubbles technique, distraction cards, coughing, and control groups) between the ages of 6 and 12. The study found that pain and anxiety levels of the children in intervention groups were lower than those of the children in the control group during phlebotomy procedure and this difference was statistically significant (P < .05). No difference was found among the three techniques (Soap bubbles, distraction cards, and coughing) to reduce pain and anxiety in children during the phlebotomy procedure (P > .05). Soap bubbles, distraction cards and coughing techniques were found to reduce pain and anxiety in children during phlebotomy. Nurses can play an effective role in reducing pain and anxiety by using these techniques.

A randomized controlled study: The effect of preprocedurals ınformative animation watch about echocardiography and ıntraprocedural kaleidoscope watch on anxiety in children

AIM

This study was conducted as a randomized controlled study to investigate the effect of procedural cartoons displayed before echocardiography and kaleidoscope display during the procedure on anxiety in children aged 5-12 years.

METHODS

The study was completed with 164 children aged 5-12 years who were admitted for echocardiography. The study was conducted with four groups: cartoons group, kaleidoscope group, cartoons + kaleidoscope group, and control group. Data were collected using a follow-up form and the Children's Fear Scale.

RESULTS

The results showed that the cartoons, kaleidoscope, and cartoons + kaleidoscope groups had lower anxiety scores during the procedure than during the preprocedural period (p < .001). In the control group, there was no significant difference between anxiety scores before the procedure and during the procedure (p > .05).

CONCLUSION

The present study concluded that cartoon display for preparing children aged 5-12 years or distracting them during the procedure using a kaleidoscope was effective in reducing their anxiety.

The Management of Burn Pain in a Pediatric Burns-Specialist Hospital

Appropriate pain management for children who have experienced an acute burn injury is critical to improve patient outcomes and reduce potential morbidities. With 60% of our patients being under the age of 4 years, pain management is crucial in reducing pain and anxiety in both patients and parents. It is imperative that appropriate pain relief is commenced from initial contact with healthcare workers as this will affect the success or failure of future wound procedures. Uncontrolled pain can negatively affect a patient, both short and long term. It may cause anticipatory anxiety for future medical procedures, increased pain and anxiety can decrease wound re-epithelialization which can lead to long-term consequences for growth and mobility, and increased pain can also influence the possibility of patients and families displaying signs of post-traumatic stress disorder. Pain management in the form of pharmaceuticals is imperative during burn wound treatment and should incorporate pain relief targeted at both background and procedural pain. It also requires a multimodal, individualized, and targeted approach combining both pharmaceutical and nonpharmaceutical techniques, including cold running water, multimodal distraction devices, hypnotherapy, and bubbles. We discuss the research and knowledge that our center has gained through treating pediatric patients with burns over the last 20 years.

Children's individual voices are required for adequate management of fear and pain during hospital care and treatment

BACKGROUND

Children often report both fear and pain in conjunction with clinical care and treatment. Interventions developed in the field have still not been sufficient to prevent and relieve children's fear and pain. More knowledge, from children's own perspectives, is needed about how they deal with their experiences.

AIM

To explore child-identified strategies that children use to manage fear and pain during needle-related medical procedures in hospital.

METHODS

Interviews with children, age 4-12 years, with experience of hospital care were analysed qualitatively using content analysis.

RESULTS

Children have self-identified strategies for dealing with fear and pain during hospital care and treatment. The strategies vary depending on examination or treatment and on how the child felt at that particular day. Children describe what they can do themselves, how adults can empower them and support from surroundings as strategies that give them a choice and a voice. Children wished to have influence, decide when and how information should be given, scream out loud or squeeze something hard, to deal with fear and pain. The results also show that children tried to be brave, gain control and think positively. Something nice to look at and opportunities to play with others also contributed.

CONCLUSIONS

Strategies vary between children and are used differently on different occasions. Healthcare professionals pose a threat to the child's needs and ability to use their strategies due to lack of knowledge of the child's chosen strategies.

Randomized Controlled Trial of Adult Therapeutic Coloring for the Management of Significant Anxiety in the Emergency Department

BACKGROUND

Anxiety and acute distress are significant concerns in the emergency department (ED). Adult coloring books are often utilized as an effective means of relaxation in waiting rooms and newsstands, but there are no reported randomized trials examining their effectiveness as a treatment for anxiety.

METHODS

We set out to examine the effectiveness of adult coloring books using a randomized placebo-controlled trial at a university-affiliated tertiary ED. Anxiety was measured using a validated self-reporting score, the Hospital Anxiety and Depression Scale (HADS-A), with a range of 0 to 21. Patients with HADS-A ≥ 7 were randomly assigned to either an adult coloring pack (n = 26) or placebo pack (n = 27). The primary outcome measure was the within-patient change in HADS-A scores following 2 hours of exposure.

RESULTS

A convenience sample of 117 patients were screened, and 53 patients were randomized. Characteristics of allocated groups were similar in terms of sex, diagnosis, and ethnicity. A higher proportion of intervention subjects spent ≥1 hour engaged with their activity (46.2% vs. 4.0%, p = 0.01). For the primary outcome measure, the mean within-patient decrease in HADS-A score at 2 hours for intervention subjects was 3.7 (95% confidence interval [CI] = 2.4 to 5.1, p < 0.001) versus a decrease of 0.3 (95% CI = -0.6 to 1.2, p = 0.51) in the placebo group.

CONCLUSIONS

Among ED patients, exposure to adult coloring books resulted in lower self-reported levels of anxiety at 2 hours compared to placebo.